Integrated Management of Post Traumatic Stress Disorder (PTSD) and Opioid Use Disorders R. Gregory Lande, DO, FACN American Osteopathic Academy of Addiction Medicine 1
R. Gregory Lande, DO, FACN, Disclosures R. Gregory Lande, DO, FACN, has no financial relationships with an ACCME defined commercial interest. The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of the Navy, the Department of Air Force, or the Department of Defense The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information. 2
Planning Committee, Disclosures AOAAM aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below: The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this module to disclose: PCSSMAT contributors: AOAAM PCSS-MAT Clinical Expert Lead and CME content reviewer: Stephen A. Wyatt, DO; Module author: R. Gregory Lande, DO and AOAAM Staff: Nina Albano Vidmer and Lara Renucci. All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products. 3
Educational Objectives At the conclusion of this activity participants should be able to: Access integrated treatment for PTSD and a cooccurring substance use disorder utilizing social interventions, evidence based psychotherapies, and pharmacologic treatments 4
Target Audience The overarching goal of PCSS-MAT is to make available the most effective medication-assisted treatments to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings. 5
Accreditation Statement The Council on Continuing Medical Education (CCME) has been delegated authority by the AOA Board of Trustees to monitor osteopathic CME and award Category 1 and Category 2 accreditation status to osteopathic CME sponsors. The purpose of the AOAAM s continuing medical education program is to continually improve the quality of patient care, through the growth of knowledge, the improvement of skills, and physician-to-physician interaction. 6
Designation Statement The American Osteopathic Academy of Addiction Medicine (AOAAM) designates this educational activity for a maximum of 1 (one) Category 2B Credit by the AOA CCME (pending all requirements are met). Physicians should claim only the credit commensurate with the extent of their participation in the activity. Released Date: March 25, 2015 Expiration Date: March 25, 2018 7
Integrated Management of Post Traumatic Stress Disorder (PTSD) and Opioid Use Disorders - Course Outline Epidemiology of PTSD & Opioid Use Disorders Factors associated with co-occurring disorders Theories associated with co-occurring disorders Integrated treatment philosophy Screening tools Management 8
PTSD - DSM V The criteria in brief: A. Exposure to actual or threatened death, serious injury, or sexual violence. B. Presence of one or more symptoms associated with the traumatic event(s) after the event. Intrusive distressing memories of the truama Recurrent distressing dreams related to the event. Dissociative reactions/flashbacks resulting in feeling or acting as if the re-experiencing the event. Intense or prolonged psychological distress at the exposure to internal or external cues of the event. Marked physiological reaction to the internal or external cues that symbolize or resemble the event. 9
PTSD - DSM V The criteria in brief cont.: C. Persistent avoidance of stimuli associated with the event. Avoidance of or efforts to avoid distressiong memories, thoughts, or feelings about or closely asso. with the event. or external reminders asso. with the event. D. Negative alterations in cognitions and mood associated with the traumatic event.marked alterations in arousal and reactivity asso. With the trauma. E. Marked alterations in arousal and reactivity asso. with the event. F. Durations of the disturbance lasting greater than 1 month. G. The disturbance causes clinically signicant distress or impair ment in social, occupational or other important functions. H.The disturbance is not attributable to the physiological effects of a substance or other medical condition. 10
Integrated Management of Post Traumatic Stress Disorder (PTSD) and Opioid Use Disorders - Epidemiology Epidemiologic studies show that individuals with PTSD also commonly have a co-existing substance use disorder A typical study reported a 36%- 50% prevalence rate of lifetime PTSD and a current PTSD prevalence rate between 25% and 42% for individuals with drug or alcohol use disorder. In terms of combat related PTSD, 25-50% of service members meeting the diagnostic criteria for PTSD will also have a substance use disorder. Reference: Suzy B. Gulliver, PhD & Laurie E. Steffen, BA: Towards Integrated Treatments for PTSD and Substance Use Disorders. PTSD Research Quarterly. VOLUME 21/NO. 2, 2010 11
Integrated Management of PTSD and Opioid Use Disorders - Epidemiology The most common substance correlated with PTSD is an alcohol use disorder, with studies reporting co-occurrences ranging between 25-84% depending on the population studied. The correlation between a cocaine use disorder and PTSD can range between 21-42% Among individuals with a heroin use disorder the rates of PTSD range from 20-31% Reference: Evridiki Papastavrou,Antonis Farmakas, Georgios Karayiannis, Evangelia Kotrotsiou: Co morbidity of Post-Traumatic-Stress Disorders and Substance Use Disorder. Health Science Journal. 5(2), 2011 12
Integrated Management of PTSD and Opioid Use Disorders Theories of Etiology Both biological and psychological factors may contribute to the co-occurrence of PTSD and an opioid use disorder A biological theory proposes that the connection between opioids and PTSD resides in the hypothalamic-pituitaryadrenal (HPA) axis. In response to the neurobiological stress induced by PTSD the HPA releases endogenous opioids. For the PTSD patient this apparently proves ineffective. Exogenous opioids prove superior at least in the short run in dampening the physiologic symptoms of PTSD. Unfortunately, tolerance to the effects of the exogenous opioids, opioid withdrawal, and the medical/social/financial consequences of opioid use intervene. Reference: Itai Danovitch, Sandra Comer,Maria Sullivan: Co-Occurring Post Traumatic Stress Disorder and Opioid Dependence: A Role for Buprenorphine. The Open Addiction Journal, 2009, 2, 21-23 13
Integrated Management of PTSD and Opioid Use Disorders Theories of Etiology Other factors promoting the co-occurrence of PTSD and an opioid use disorder include: The lifestyle associated with a severe opioid use disorder increases the risk of illness, injury, abuse, and victimization increasing the likelihood of a trauma sufficient for PTSD. The trauma associated with the subsequent PTSD may have involved physical injuries, such as sustained in combat or a motor vehicle accident, which eventuate in chronic pain management anchored in opioid use. The increasing misuse of prescription analgesics. 14
Integrated Management of PTSD and Opioid Use Disorders Screening The high correlation between substance use disorders and PTSD should encourage every clinician to screen for these dual diagnoses. Standardized screening tools can supplement the clinician s evaluation. A few examples might include the Post Traumatic Stress Disorder Checklist (PCL) and for substance use disorders clinicians might consider the Alcohol Use Disorders Identification Test (AUDIT) and the Brief Addiction Monitor (BAM) 15
Integrated Management of PTSD and Opioid Use Disorders Integrated Treatment The ideal management of PTSD and an opioid use disorder would come through an integrated treatment plan that would seamlessly address both problem areas. In reality, this ideal may be hard to achieve. Patient resistance and clinical resources are rate controlling factors. Even so, a body of evidence is emerging which will point towards best practices. As always, clinicians must remain aware of new advances and clinical recommendations. 16
Integrated Management of PTSD and Opioid Use Disorders Psychotherapies Integrated treatment approaches include both medication management, psychotherapies, and social interventions. Suggested psychotherapies for PTSD include: Seeking Safety Cognitive Processing therapy Prolonged Exposure Eye Movement Desensitization and Reprocessing Stress Inoculation Training Group Treatment Family Therapy Reference: Overview of the 2010 VA/DoD Clinical Practice Guideline for PTSD @ http://www.ptsd.va.gov/professional/ptsd101/ptsd101-pdf/brch-overview.pdf 17
Integrated Management of PTSD and Opioid Use Disorders Psychotherapies Seeking Safety Seeking Safety is a present- focused coping model for PTSD and substance use disorders. The structured treatment consists of 25 topics, Seeking Safety can be done as a group or individual It is the most researched model of its type Reference: See http://www.seekingsafety.org 18
Integrated Management of PTSD and Opioid Use Disorders Medication Pharmacologic Guidelines for Treating Individuals with Post- Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders* Assembled by a task order work group, which included federal SAMHSA staff and contractors. The guidelines were reviewed and rated by an expert Consensus Panel The panel was made up of 33 individuals who are identified as experts in psychiatry, pharmacotherapy, COD, mental health, addictions, health center administration, and health reform. *Reference: Excerpts from Pharmacologic Guidelines for Treating Individuals with Post-Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders @ http://www.samhsa.gov/co-occurring/docs/pharm_guidelines_508.pdf 19
Integrated Management of PTSD and Opioid Use Disorders Medication Selected Excerpts from the Pharmacologic Guidelines for Treating Individuals with Post- Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders Pharmacotherapies for individuals should be based on The severity of the opioid use disorder and the PTSD; The response to previous treatments for PTSD and/or opioid dependence Other concomitant medications; An analysis of the risks and benefits of any medication therapy 20
Integrated Management of PTSD and Opioid Use Disorders Medication Selected Excerpts from the Pharmacologic Guidelines for Treating Individuals with Post-Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders Pharmacotherapies shown to be effective for PTSD include: Selective Serotonin Reuptake Inhibitors (SSRI) are first-line treatments (sertraline and paroxetine are FDA-approved Paroxetine has the potential to inhibit methadone metabolism, which could result in increased blood levels of methadone 21
Integrated Management of PTSD and Opioid Use Disorders Medication Selected Excerpts from the Pharmacologic Guidelines for Treating Individuals with Post- Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders Pharmacotherapies for the treatment of opioid use disorders are described in SAMHSA s Treatment Improvement Protocols (TIP) TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (http://buprenorphine.samhsa.gov/bup_guidelines.pdf) (McNicholas, 2004) TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs (http://store.samhsa.gov/product/sma08-4214) (Center for Substance Abuse Treatment, 2005). 22
Integrated Management of PTSD and Opioid Use Disorders Summary Integrated treatment for co-occurring disorders involves the thoughtful and skillful use of social interventions, evidence based psychotherapies, and pharmacologic treatments 23
Question 1: The incidence of Substance Use Disorder (SUD) with PTSD is: A. 10% B. 20% C. 50% D. 90% E. 80% Complete Post test for answer. 24
Question 2: The first step in treating the patient is to: A. Get his PTSD symptoms in control, B. Engage the patient in understanding how his substance abuse disorder drives his worsening symptoms of PTSD and vice versa, C. Refer him to an opiate treatment clinic to start methadone, D. Send the patient to residential treatment for his opiate use disorder. E. Refer him to pain management. Complete Post test for answer. 25
Question 3: 3. The evidence would indicate the most helpful treatment of the patient s pain would be: A. Abstinence, Paroxetine, Seeking Safety; B. Methadone maintenance, Paroxetine, Seeking Safely; C. Methadone maintenance, Sertraline, insight oriented psycho-therapy; D. Buprenorphine maintenance, Sertraline, and Seeking Safety; E. Buprenorphine alone Complete Post test for answer. 26
Question 4: PTSD symptoms include the following except: A. Recurrent nightmares B. History of being easily startled C. Fear of driving on the expressway D. Poor sleep architecture E. Constipation Complete Post test for answer. 27
Integrated Management of Post Traumatic Stress Disorder (PTSD) and Opioid Use Disorders - Vignette R. Gregory Lande, DO, FACN American Osteopathic Academy of Addiction Medicine Patient is a 32-year old married Caucasian male with a history of substance abuse problems. He presents with sleeplessness and anxiety. He has a family history of alcohol use disorders involving his paternal grandfather and 2 paternal uncles. He had no childhood history of psychiatric problems but he was a self-described shy child. He started drinking at 14-years old and admits to multiple blackouts in high school. At 26-years old he was in a solo motor vehicle accident, resulting in pelvic and sternal fractures. He was hospitalized for 2 weeks. He was continued on pharmaceutical opioids after discharge until age 29, when it was discovered that he was receiving opioids from more than one doctor. His opioids were discontinued and he was sent to an opiate detox center. Following the detox, he was maintained on non-opioid pain medication for recurrent hip pain. Six weeks after this treatment episode he relapsed to non-prescription opioids and a year later, was using heroin by intra-nasal insufflation. He first started using heroin by injection six months prior to this presentation. He had recurrent nightmares resulting in poor sleep maintenance following the accident. He has been unable to drive on an expressway, he describes a history of being easily startled. These problems have contributed to a recurrent depressed mood and intermittent suicidal ideation. This constellation of problems has contributed to his inability to work consistently as a construction worker and has contributed to marital strife. He describes loving his wife and children but feels worthless and unworthy. He is seeking help. 28
Case Question 1: A substance use evaluation includes all of these following, except: A. History of blood relatives with substance use disorders B. Types, amounts, duration of time substances were used C. Risk for self-injurious behaviors: intent, plan, protective factors D. School grades and SAT scores from elementary through high school E. Psychiatric history during the patient s childhood and adolescence. Complete Post test for answer. 29
Case Question 2: Which of the following characteristics is least likely to contribute to a diagnosis of opioid use disorder? A. History of alcohol use disorder-severe B. Out of control opioid use after motor vehicle accident C. Continued use of prescription opioids after motor vehicle accident D. Nasal insufflation abuse of heroin E. Injection drug use of heroin Complete Post test for answer. 30
Case Question 3: PTSD symptoms include the following except: A. Recurrent nightmares B. History of being easily startled C. Fear of driving on the expressway D. Poor sleep architecture E. Constipation Complete Post test for answer. 31
References Evridiki Papastavrou,Antonis Farmakas, Georgios Karayiannis, Evangelia Kotrotsiou: Co morbidity of Post-Traumatic-Stress Disorders and Substance Use Disorder. Health Science Journal. 5(2), 2011 * Excerpts from Pharmacologic Guidelines for Treating Individuals with Post- Traumatic Stress Disorder and Co-Occurring Opioid Use Disorders @ http://www.samhsa.gov/co-occurring/docs/pharm_guidelines_508.pdf Itai Danovitch, Sandra Comer,Maria Sullivan: Co-Occurring Post Traumatic Stress Disorder and Opioid Dependence: A Role for Buprenorphine. The Open Addiction Journal, 2009, 2, 21-23 Overview of the 2010 VA/DoD Clinical Practice Guideline for PTSD @ http://www.ptsd.va.gov/professional/ptsd101/ptsd101-pdf/brch-overview.pdf Suzy B. Gulliver, PhD & Laurie E. Steffen, BA: Towards Integrated Treatments for PTSD and Substance Use Disorders. PTSD Research Quarterly. VOLUME 21/NO. 2, 2010 See http://www.seekingsafety.org 32
PCSS-MAT Mentoring Program PCSS-MAT Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction. PCSS-MAT Mentors comprise a national network of trained providers with expertise in medication-assisted treatment, addictions and clinical education. Our 3-tiered mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available, at no cost to providers. For more information on requesting or becoming a mentor visit: pcssmat.org/mentoring 33
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PCSSMAT is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society of Addiction Medicine (ASAM) and Association for Medical Education and Research in Substance Abuse (AMERSA). For More Information: www.pcssmat.org Twitter: @PCSSProjects Funding for this initiative was made possible (in part) by Providers Clinical Support System for Medication Assisted Treatment (5U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. 35
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